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HomeMy WebLinkAboutCRT2008-00014 - CRT Application - 4/29/2008 MASON COUNTY DEPARTMENT OF HEALTH SERVICES 426 W CEDAR ST., PO BOX 1666, Shelton WA98584 SHELTON (360) 427-9670 Ext: 352 ELMA(360)482-5269, BELFAIR(360)275-4467 WEB: http://www.co.mason.wa.us FAX: (360)427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INFORMATION TYPE OF REVIEW Receipt Number: S1200800000000000868 CRT2008-00014 Payment Type: Check Property Evaluation Date of 04/29/2008 Important Notice: Findings &determinations of this review reflect observed conditions as they existed n the day the evaluation was preformed.Absolutely no claim is made by this office, expressed or implied concerning Me future success, failure or permit approval of the system and site evaluated. **FILL OUT APPLICATION COMPLETELY AND ACCURATELY*`* An application is considered complete when the fee is paid, parts 1, 2 and 3 of this application form are completed, necessary paperwork is attached (i.e. pumpers report)and when required, soil evaluation holes have been excavated. PART 1. APPLICANT PARCEL IDENTIFICATION Applicant: M DOREEN ROUTLEDGE Telephone: 360-374-8901 Mailing Address: 5300 GLENWOOD AVE Citv: EVERETT State: WA Zip: 98203 Parcel Number: 221075000045 Site Address: 1330 E MASON LAKE DR SOUTH GRAPEVIEW Brief Legal Description: MASON LAKE ESTATES TR 45 Driving Directions: JOB SITE IS ON THE EAST SIDE CLOSE TO SIMPSON PARK, 11 IS THE LOT NEXT TO A BLACK MAIL BOX MARKED STAFNE, THE CABIN IS GRAY PART 2. TYPE OF REVIEW Septic System Age of system: Age of house: Number of bedrooms: Name of last owner: Is house currently occupied?: If not occupied, how long has it been vacant?: Water System Number of service connections on the water system?: If a public water system, name of system: WFI number: Proprety Evaluation (soil logs) Property evaluations provide, in general terms, the suitability of a parcel for septic sy3tem placement. THIS DOES NOT GUARANTEE FUTURE SEPTIC SYSTEM APPROVAL. Describe the intended use of the property and the reason for requesting the review The description of the intended use is not included in this report. PART 3. PLOT PLAN Use the space below to draw a detailed plot plan, or attach a detail plot plan to this application. The plot plan should include the following: North Arrow, Precise Location of Test Hoes, Location of Existing Septic System, Dimensions of Property, Location of any Drinking Water Sources (wells, springs, etc), Roads, Easements, Surface Water, and Buildings on the Property. LOT SIZE x Acres The applicants plot plan is not included in this report. NEW Applicant Signature: Signature is not included in this report. Date: The date is not included in this report. CRT2008-00014 2 of 4 PART 4. HEALTH DEPARTMENT FINDINGS -- OFFICIAL USE Septic System The septic tank was inspected by a certified septic tank pumper within the last 3 years and was found to be in satisfactory condition. A pumpers report is attached. Records for this property contain a septic permit, design, final inspection approval and an as-built drawing. The site was inspected and the system location appears to be consistent with recorded documents. The area of the on-site system appears to be maintained in an acceptable manner. Was Operation and Maintenance a condition of permit approval? Is a copy of current Operation and Maintenance report attached? Water System Individual Water System A water sample was taken by health department staff and analyzed. Total colifo m bacteria were determined to be absent. Laboratory results are attached to this report. The well cap was inspected. The sanitary seal appears satisfactory The well casing was inspected. The casing projected above ground and the ground was sloped away from the casing The well site was inspected. No septic systems, chemical storage facilities, man re piles, animal feedlots or other obvious sources of contamination appeared within 1 00- oot radius of the well. Public Water System Records indicate water-sampling requirements are being satisfied. Records indicate the Water Facility Inventory form is current. Department files contain water system design and letter of approval Soil Conditions Test Hole#1 Test Hole #2 Test Hole #3 Soil Type Soil Type Soil Type Restr. Layer Restr. Layer Restr. Layer Slope Slope Slope Distant to Shoreline Distant to Shoreline Distant to Shoreline CRT2008-00014 3 of 4 PART 5: HEALTH DEPARTMENT OBSERVATIONS -FOR OFFICIAL USE ONLY Primary Drainfield Staff inspected the primary drain field area and when available, pertinent records were re iewed. The following determination was made The system appears to be functioning adequately at the time of the inspection. (only applicable ifs stem has been in use on a regular basis for the last 6 months Sanitary Survey? Survey Results Water System Staff evaluated the water system and the following determination was made The water source consists of an individual well the appears to be a satisfactory source of potable water for a single-family residence. The water was sampled and colifo m bacteria were absent. The water source is a public water system that appears to be in compliance with the applicable regulations Well Construction Permit Permit Status PART 6: COMMENTS Site Evaluation: There were no test holes to be evlauated. It appears this applicant inter ded to have a site pre-inpection by planning rather than in environmental health review. I have attem ed to contact the applicant, but the phone number on application is disconnected. INSPECTOR DATE Important Notice: Findings & determinations of this review reflect observed conditions as they existed on the day the evaluation was preformed. Absolutely no claim is made by this office, expressed or implied concerning the future success, failure or permit approval of the system and site a aluated. CRT2008-00014 4 of 4 N COUNTY C HEALTH .I V426 W CEDAR ST.,PO BOX 1666,SHELTON,WA 98584 MASC)NS$OtMT360)427-9670,Ext: 352, ELMA(360)482-5269, BELFAIR(360)275-4467 WEB: han//www.co.mason.wa.us FAX:(360)427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INNFOR('MATION TYPE OF REVIEW CRT Roe eip or 3�_ ❑ Septic and Water $300 ❑ Cash ❑ Septic $165 )Q Check (1 ❑ Water $185 (Individual and Two Party) El Group B WS $55.00(+$55.00/hour eyond 1 hour) Date of Payment a Property Evaluation $250 ❑ Resample $18 lab fee Important Notice: Findings & determinations of this review reflect observed conditions as they exist on the day the evaluation was performed. Absolutely no claim is made by this office, expressea or implied concerning the future success, allure or ermit a roval o the s stem and site evaluated ****FILL OUT APPLICATION COMPLETELY AND ACCURATELY**** An application is considered complete when the fee is paid,parts 1, 2, and 3 of this application form are completed,necessary paperwork is attached(i.e. pumpers report) and when required soil evaluation holes have been excavated. PART 1. APPLICANT/PARCEL IDENTIFICATION 7 p p Name of Applicant (12 f �In �i�ti �d�`� Telephone 3 b 0 3 4 f C Mailing Address of AApplicant J' 3G G L142kLJ66A CA , City I U AIL PP 1 State �-k3a Zip I 12-digit Tax Parcel No. CJ G Site Address G S G N g, 0 `E d Brief Legal Descriptionl'tti)C t2�C�G✓/ �� 6 (� t C -�" C-j eli rz. 511 >t S i0 u 4h e, ::> U, et ►L Cr ie 1M 'e �A4'n r a Ge how,E� Driving Directions +c) 113 a lyfq OLI 1C"(Z-'-- �L K Page 1 of 4 PART 2: TYPE OF REVIEW ❑ Septic System (^ • Age of system IQ s4ec� -rtS • Age of house ,�L, 4 • Number of bedrooms / • Name of last owner . S t i 1 • Is house currently occupied? ❑ YES 5.NO • If not occupied,how long has it been vacant? to S "fw a r"C. G Na YZ ❑ Water System • Number of service connections on the water system? • If a public water system, name of system • WFI number roperty Evaluation (soil logs) roperty evaluations provide, in general terms, the suitability for a parcel for septic system placement. THIS DOES NOT GUARANTEE FUTURE SEPTIC SYSTEM APPROVAL. • Describe the intended use of the property and the reason for requesting the review. PART 3: PLOT PLAN Use the space below to draw a detailed plot plan, or attach a detailed plot plan to this application. The plot plan should include the following: North Arrow, Location of Test Holes, Location of Existing Septic System, Dimensions of Property, Location of any Drinking Waster Sources (wells, springs, etc.) Ro Easements, Surface Water, and Buildings on the property. LOT SIZE TRH C `C•, X i;x � � v Ares COMPASS (o Applicant's Signature: 2�2� - j x << Date Page 2 of icy« Mason County Map Output Page Page 1 of 1 Mason Count Ma +�,senta.k� r f rySC� 6rpW '_ 1 -33a 0" La ke f r X0 322ft DISCLAIMER AND LIMITATION OF LIABILITY: The data used to make this map have been tested for accuracy,and every effort has been LEGEND made to ensure that these data are timely,accurate and reliable.However,Mason County makes no guarantee or warranty to its accuracy as to labeling,dimensions,or placement or location of any map features contained herein.The boundaries depicted by these data are approximate,and are not necessarily accurate to surveying or engineering standards,and are , intended for informational purposes only.Mason County does not assume any legal liability or responsibility arising from the use of this map in a manner not intended by Mason County. ,. ,�;xiPr 6•>o.,d i)V tl.;.^i In no event shall Mason County be liable for direct,indirect,incidental,consequential, ' special,or tort damages of any kind,including but not limited to,loss of anticipated profits or benefits arising from use of or reliance on the information contained herein 0 2006-Mason County 415 N.Sixth Street __._ T ,r :et P 1 t ,aU :t a.y Shelton,WA 98584 http://mapmason.co.mason.wa.us/servlet/com.esri.esrimap.Esrimap?ServiceName=amason .. 4/29/2008 BENERAI SERVICE$,PARTUM 1229; P.O..BOX 188!303 NORTH 4th STR •YSHELTON;WA go" PHONE p2", L RECORD OF F# 4AL JNISPECTION OF YOUR SEWAGE DISPOSAL SYSTEM ADDRESS Y THIS RE R915 A GUARftXTEE OF PERFORMANCE CITY ASEfxTIC5Y& At#S'NOTAMUN�PAt 1NlER:#10YkEYER c V jWoETd ANCE AND CAREFUL USE OF. t 440 EtCYNA Y ARSOFTROUBLE FRK-SER Y 5EPT1C 7hNT4S ARE CAL0D SOIL COMMENTS DINTS OF PAPER, CLOTH Ind �'#ERIAL�u D(7WN THE DRAIN, OR,$Y Sf UE FAfi*f EIXF RES MONTH W/D ATTF TABLE - - "-OF Of YEAR 'MOULD BE CLEANED EVERY INSTALLER T EPENNNO ON tHI:HABTFS OF THE <xR#N�3"1A1�T h T4# (A VUOIPDJ THE1 R�� ?A£ K OTA,A (S) RISK OF WiU I "VRAINFIELD DUE TO SOLIDS: PgANFIHIi- line—) e r DRA"F[Ew" : L. THE TRENCH AREA NE H1►tTH DEPARTMENT FOR A tiST QF kS ElvlS C T Nk-CLEANE IN YOURAkt NER. sorftyE You BE5f IF YOU R. REt GIRD He COMES. ROCK H' TOTAL HEAVY TES OR EQUIPMENT SHOULD NE�RBE CLLLDS. t#L DEtLTkI °,j#ifER (HE tANk:OR DRAINFIELD. CONSI I te,HIS SPACE IifSERVE6 FOR SQ. FT,; R+I ,� OF ANY BUILDFNGS, DRIVEWAYS: REPI/tCEl41ENF`DISTRIBUTIO .FIELD: S OR EXTENSIVE GRADING OR FILLING #-NOON r e.f t_ > .I' SH®IitD NOC BET kNTEiJ_aoETo AS TtiEf LLD tNtERf RE TI . t At TA VIV . , lIIICIOW¢5 ARE NOT ttSED 7 6 'SucYiIA NOT POCIfETEF3 JnV ON THE IN'WIITH SOIL, bd,m' T EX THE iAWIN IP! THE DRAINFIEID AREA. IOt<I'fROM THE DRAINFIELD IS/K80L1T �` Y "N PER DA?l .may , p ,. " WtNSPOUTS �5 �`. © L4A a �"'.. {w SSTFlVLOR(?IS ►TARGDLFflTHE c a #LiEfi1PES,OF OA PIEEDED•TPI A S€P`fIC"€ANK ARE s< E t kS� lll /AGE THERE IS NO NE1640 ADD' ittERS TftA SYSTEhA.Ti9E USED"RE- { ? } ;e ,P t'AIS'TO tl€AN A S1 PT ANK e�x I*TPktTVEN TO BE' FRk PkY BE RDC $Ni SHING SOLIDS OUT OF h"" OR BY THE tHAFLKGTERiSTIGS L..THE IRlj aOF 66WL C(tANERS OR CLEJM1#NM OOM- SOUTH x # K�IL#1 BACmIAtA>:.IIOt OkSIOVv DP RATION OF THE SEPTIC TANK. f � NXTUM OF INSTALLER 'MIS} AN PAP, NT DOCUMENT DATE 1owPliu51YLTH IJEEA OR OTHER [rlsPEmoR o. N It.ld ly ems' ssgg� \`mac+\c\ ••r•... \� ,tI �y� 0 its o v y u 115Y ��1 L91�'Gi.\ ti• �•y it At .64 zki .otA It" kD �XV*�, TA �Ig�k4k'911 V� Lp Yj \ \ . •__i3.9E p1•pN moo. IJ 1° _ PS \ \\ F-• Z5 / LL \N i .01 6b Ile \\N .1k / C �h. goo �4/ pp' �3oy s// e PART 4: HEALTH DEPARTMENT FINDINGS—OFFICIAL USE ONLY Septic System Yes No ❑ ❑ The septic tank was inspected by a certified septic tank pumper within the last 3 years and was found to be in satisfactory condition. A pumpers report is attached. ❑ ❑ Records for this property contain a septic permit, design, final approval and as as-built drawing. ❑ . ❑ The site was inspected and the system location appears to be consistent with recorded documents. ❑ ❑ The area of the on-site system appears to be maintained in an acceptable manner. ❑ ❑ Was Operation and Maintenance a condition of permit approval? ❑ ❑ Is a copy of a current Operation and Maintenance report attached? Water System Yes No Individual Water System ❑ ❑ A water sample was taken by health department staff and analyzed. Total coliform bacteria were determined to be absent. Laboratory results are attached to this report. ❑ ❑ The well cap was inspected. The sanitary seal appears satisfactory. ❑ ❑ The well casing was inspected. The casing projected above ground and the ground 31oped away from the casing. ❑ ❑ The well site was inspected. No septic systems, chemical storage facilities, manure pile, animal feedlots or other obvious sources of contamination appeared within a 100-f of radius of the well. Yes No Public Water System ❑ ❑ Records indicate water-sampling requirements are being satisfied. ❑ ❑ Records indicate the Water Facility Inventory form is current. ❑ ❑ Department files contain water system design and letter of approval. Soil Conditions Test Hole#1 Test Hole#2 Test Hole#3 Soil Type: Soil Type: Soil Type: Restrictive layer: Restrictive layer: Restrictive layer: Slope: Slope: Slope: Distance to Shoreline: Distance to Shoreline: Distance to Shoreline: Page 3 of 4 PART 5: HEALTH DEPARTMENT OBSERVATIONS—FOR OFFICIAL USE ONLY Primary Drainfield Yes No ❑ The system appears to be functioning adequately at the time of the inspection. (On] applicable if system has been in use on a regular basis for the last 6 months.) ❑ ❑ Sanitary survey? ❑ Pass ❑ Fail ❑ Suspect ❑ Not applicable Water System Yes No ❑ The water source consists of an individual well that appears to be a satisfactory source of potable water for a single-family residence. The water was sampled and coliform bacteria were absent. ❑ ❑ The water source is a public water system that appears to be in compliance with applicable regulations. ❑ ❑ Well Construction Permit ❑ Pass ❑ Fail PART 6: COMMENTS INSPECTOR DATE Important Notice: Findings &determinations of this review reflect observed conditions as they exist on the day the evaluation was performed. Absolutely no claim is made by this office, expressed or implied concerning the future success, failure or permit approval of the system and site evaluated. Page 4 of 4 Certification Application Fomt.doc Updated 1/2006